Senior Medical Director Precertification Team

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Position Summary:

Aetna, a CVS Health Company, has an outstanding opportunity for a Senior Medical Director to provide end-to-end clinical and operational leadership for Medicare and other activities, ensuring the highest standards of quality, compliance, and efficiency across the continuum of services. This leader is responsible for developing, training, and managing the Precertification Team, ensuring compliance, efficiency, and evidence-based decision making, driving process improvement, and fostering a collaborative team culture. This senior level MD serves as a key liaison between clinical and non-clinical stakeholders to ensure effective operations, communication, and strategic alignment.

This role provides strategic leadership and oversight for clinical operations by developing and implementing clinical policies and protocols, ensuring high-quality patient care, overseeing clinical functions, promoting evidence-based practices, and collaborating with cross-functional leaders to improve clinical outcomes and patient safety. They apply medical expertise, leadership skills, and knowledge of industry standards to drive clinical excellence, optimize resources, and contribute to the overall success of the organization's clinical operations.

Primary Job Duties & Responsibilities:

• Provides strategic direction, professional oversight, and leadership throughout the
  precert process and other clinical operations.

• Collaborates with executive leadership to develop and implement strategies that align with healthcare objectives, improve processes, drive innovation, and positively impact members and providers.

• Leverages medical and operational expertise to develop and align the company's goals with clinical strategies and regulatory requirements.

• Collaborates with cross-functional leaders to shape and drive the clinical operations strategy and initiatives, ensuring optimal quality and efficiency.

• Establishes clinical standards and oversees clinical governance structures to ensure patient safety and the provision of quality care.

• Leads the development of clinical processes and programs, such as clinical protocols, guidelines, treatment pathways, and training curricula.

• Manages operations of the Medicare Precertification MD Team, in alignment with governing policies and procedures.

• Leads teams through Medicare audits and on-going audit readiness.

• Stays updated on relevant scientific evidence, industry standards, and regulatory changes to ensure organizational compliance and relevance.

• Develops and maintains relationships with key stakeholders, such as government agencies, providers, and professional organizations.

• Develops and continuously monitors key metrics to assess the performance of strategic initiatives and processes, making adjustments as needed.

• Provides mentorship, professional development opportunities, and support to physicians, promoting their growth and ensuring a cohesive and skilled medical team.

• Collaborates with legal and compliance teams to ensure developed clinical processes and solutions comply with all applicable regulatory requirements.

Required Qualifications:

• MD or DO with active, unrestricted license and board certification in an ABMS or AOA recognized specialty

• Minimum 5 years of direct patient care in a clinical setting

• Minimum 5 years in utilization management, precertification, or related roles

• Deep expertise in Medicare regulations, including NCDs, LCDs, Medicare manuals, and regulatory references

• Proven ability to interpret and apply Medicare guidelines to complex case review and decision-making

• Advanced knowledge of medical coding standards, compliance requirements, and oversight of coding practices

• Demonstrated leadership in managing teams, driving process improvement, and ensuring regulatory compliance

• Successful track record guiding teams through Medicare audits and maintaining audit readiness

• Strong interpersonal, communication, and cross-functional stakeholder management skills

• Commitment to developing talent and fostering an inclusive, high-performing team culture

Preferred Qualifications:

• Experience working in large, matrixed healthcare organizations

• Familiarity with data analytics and performance management tools

• Certified Professional Coder (CPC) credential or equivalent certification

• Proficiency with multiple documentation platforms for acute utilization management and appeals

• Prior leadership roles with increasing responsibility

Education:
MD or DO

Pay Range

The typical pay range for this role is:

$184,112.00 - $396,550.00

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.  The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.  This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.  This position also includes an award target in the company’s equity award program. 
 

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.

• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.

• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit https://jobs.cvshealth.com/us/en/benefits

We anticipate the application window for this opening will close on: 05/01/2026

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.